You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
Our client is seeking a Prior Authorization Nurse who will be primarily responsible for reviewing referrals for medical services to assess medical necessity and determine appropriate actions. This role requires independent judgment, extensive medical knowledge, and adherence to clinical guidelines. The nurse will collaborate with the Nursing Manager, VP of Clinical Policy, and the Medical Director on matters of utilization management and problem-solving.
Responsibilities / Job Duties
- Review prior authorization referrals to evaluate medical necessity using independent judgment and medical expertise.
- Assess patient records to determine how patients meet criteria for requested services.
- Ensure compliance with health plan, state, and clinical guidelines when making decisions.
- Develop clinical summaries to justify approval or denial recommendations for requested services.
- Make recommendations for the Medical Director's review when services do not meet criteria.
Minimum Education and Experience Qualification Requirements
Education
- Bachelor’s or Associate Degree in Nursing (Bachelor’s preferred).
- Current CA State licensure as a Licensed Vocational Nurse (LVN).
Qualifications
- At least 2 years of experience in a comparable position.
- Prior authorization or Managed Care experience preferred.
Skills
- Ownership/Dependability: Takes responsibility for meeting goals and objectives, manages time effectively, and demonstrates accountability for errors.
- Attendance: Maintains excellent attendance and dependability due to the nature of the department.
- Attention to Detail: Capable of paying close attention to all details in medical records and clinical guidelines.
- Business Acumen: Professionally represents the company and demonstrates a positive approach to the job.
Additional Requirements
- Must be able to work in a seated position for long periods of time.
- Must have the ability to use fingers, hands, and arms at a computer keyboard for extended durations.
Benefits
- Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
- Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
- 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
- Short Term Disability Insurance.
- Term Life Insurance Plan.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
